White Lake Senior Center
Volunteer Service Form

NAME___________________________________________________________________

MAIDEN OR PREVIOUS NAME _____________________________________________

ADDRESS_______________________________________________________________

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CITY _______________________STATE_______________ZIP CODE_______________

PHONE _____________________SOCIAL SECURITY ___________________________

DRIVERS LICENSE #_______________________ DATE OF BIRTH ________________

HAVE YOU EVER BEEN CONVICTED OF A CRIME? YES________NO_________

IF YES, PLEASE EXPLAIN FURTHER _______________________________________

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DAYS AVAILABLE (please circle) MON TUES WED THURS FRI SAT SUN

HOURS AVAILABLE ______________________________________________________

EXPERIENCE, SPECIAL SKILLS & TRAINING YOU HAVE

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FUND-RAISERS YOU WOULD LIKE TO HELP OUT WITH

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ACTIVITIES YOU WOULD LIKE TO HELP OUT WITH

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REFERENCES ____________________________________________________________

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EMERGENCY CONTACT __________________________________________________

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